Diagnosis and treatment of BPH with idiopathic OAB Dongdeuk Kwon, MD, PhD

Diagnosis and treatment of BPH
with idiopathic OAB
Dongdeuk Kwon, MD, PhD
Department of Urology,
Chonnam National University Medical School
CHONNAM NATIONAL UNIVERSITY MEDICAL SCHOOL
 BPH
 Idiopathic OAB, not neurogenic
 Mechanism between them and recent treatment
CHONNAM NATIONAL UNIVERSITY MEDICAL SCHOOL
Male and female LUTS
 Male and female
with urinary urgency, frequency and nocturia
 antimuscarinic for female OAB
 alpha blocker for male BPH
 Initial empiric diagnosis of BPH may be correct, in male
 But, not all cases of male LUTS equate to BPH
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Shift in our understanding of
LUTS in males
 43% of older men with LUTS
 suffer from DO, Not BOO
Hyman MJ, Groutz A, Blaivas JG. J Urol 2001; 166: 550–3.
 Only 50% of men with preoperative DO
 resolution of DO after outlet reduction
surgery
Van Venrooij GE, Van Melick HH, Eckhardt MD et al. J Urol
2002; 168:605–9.
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paradigm shift for patient care
 men under 50 with LUTS, do not have BPH
 symptoms are to another cause
Kaplan SA et al. Urology 1996; 47:836–9.
 Regardless of the underlying cause,
 if symptoms are not resolved as a result of
prescribed therapy,
 suffer needlessly or even undergo
unnecessary prostate surgery
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Definition of BPH
 BPH
 Microscopic, prostatic hyperplasia,
 benign proliferation of the prostatic
stroma and epithelium
 BPE
 enlargement of the prostate gland
 diagnosed with clinical or
ultrasound examinations
 BOO
 Enlargement of the prostate with
LUTS
Lee C. proceedings of the Fifth International Consultation of Benign
Prostatic Hyperplasia, Chapter 3. London: Health Publications, Ltd.,
2001:79–106.
CHONNAM NATIONAL UNIVERSITY MEDICAL SCHOOL
Rosenberg MT et al. Int J Clin Pract
2007;61:1535-46
Pathophysiology of LUTS and OAB
 LUTS, multifactorial
 OAB, a symptom complex, unknown aetiology
 voiding symptoms of BPH
 by prostatic enlargement
 storage symptoms of BPH
 by remains controversial
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Identifying LUTS
 Screening tools
 AUA symotome score, IPSS sheet
 History, physical and laboratory exam
 identify other causes of the LUTS, reversible issues or
comorbidities
 medications, family history or prior surgeries
 Key to the proper evaluation of LUTS
 voiding volume
 voids small amounts, frequently
 urologic function is more likely to be abnormal
 voids normal amounts, frequently
 Medical cause is more likely than a urologic cause
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LUTS; differential diagnosis and other causes
Differential diagnosis
Medications
Other risk factors
Consider
May cause or exacerbate LUTS:
Consider:
Bladder cancer
Tricyclic antidepressants
Obesity
Prostate cancer
Anticholinergic agents
Cigarette smoking
Prostatitis
Diuretics
Regular alcohol consumption
Bladder stones
Narcotics
Elevated blood pressure
Interstitial cystitis
First-generation antihistamines
Radiation cystitis
Decongestants
Urinary tract infection
Diabetes mellitus
Parkinson’s disease
Primary bladder neck hypertrophy
CHF
Lumbosacral disc disease
Multiple sclerosis
Nocturnal polyuria
CHF, congestive heart failure.
Rosenberg MT et al. Int J Clin Pract
2007;61:1535-46
Focused physical examination
 Abdominal examination for tenderness, masses or an
overdistended bladder
 Neurological examination with mental and ambulatory
status and neuromuscular function
 Genitalial examination, meatus and testes
 DRE, rectal tone and prostate size, shape, consistency
Speakman MJ et a. BJU Int 2004; 93: 985–90.
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Labaratory test
 Urinalysis by dipstick or microscopic
 strongly recommended for blood, protein, glucose or any
signs of infection
 PSA
 Blood sugar, either random or fasting
 not included in AUA guidelines
 Urine cytology, optional
 Haematuria with storage symptoms or at risk for bladder
cancer
 Serum creatinine
 no longer indicated
Roehrborn et al. AUA, Education and Research, Inc., 2003.
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Is it OAB or BPH?
 Differentiate between storage and voiding issues
 Cannot make a definitive diagnosis of obstruction
without advanced testing, such as urodynamics
 Storage issues affect the bladder
 consider OAB
 Voiding issues relate to obstruction and urine expulsion
 Focused on prostate
 Many patients exhibit both OAB and BPH
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Provisional BPH and Provisional OAB
 Empiric medical therapy
 Behavioural modification
 Pressure-flow studies, PVR urine
 Not necessary prior to medical therapy by AUA guidelines
Roehrborn et al. AUA, Education and Research, Inc., 2003.
 Bothersome LUTS
 Enlarged prostate (> 30 ml)
 PSA > 1.4 ng/ml
 increased risk of acute urinary retention
 dual therapy with an alpha blocker and a 5ARI 24,37
McConnell JD et al. N Engl J Med 2003; 349: 2387–98.
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diagnosis of OAB
as the cause of the LUTS
 Treatment for BPH proves ineffective
 add treatment for OAB
 risk of retention
 Small repeat the PVR (50 ml)
 Good flow rate (8 ml/s)
 diagnosis of OAB as the cause of the LUTS
CHONNAM NATIONAL UNIVERSITY MEDICAL SCHOOL
Treatment of OAB: behavioural and
pharmacologic therapy
 Behavioural therapy
 patient education
 bladder retraining, urge suppression techniques
 dietary alterations
 changing the timing of medications (e.g. diuretics)
 encouraging exercise and weight loss
 Pharmacologic therapy
 antimuscarinic therapy
 darifenacin, oxybutynin, solifenacin, tolterodine
trospium, transdermal form of oxybutynin
 Combination therapy
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Place of anti-diuretic hormone for
nocturia due to BPH
 Nocturia
 polyuria, diabetis mellitus, neurological bladder,
cardiac failure, polydipsia, reduced bladder capacity,
insomnia or psychiatric problems
 Act on BOO, on bladder sensitivity by anti-cholinergic
drugs, on sleepiness by hypnotic drugs, on urinary
volume by anti-diuretics
 Desmopressin
 number of nocturnal voids 3 -> 1.7 (43%)
 duration of the first sleep period 61-> 269 min(59%)
 total volume of urination 1.5-> 0.9 l
Lose G et al. J Urol 2004;172(3):1021–1025
Abrams P et al. BJU 2002;Int 90(Suppl 3):32–36
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OAB with BPH
 40–70% of BOO
 OAB due to detrusor overactivity
Hyman J Urol 2001;166(2):550–552




ischemia
cholinergic detrusor denervation
increased detrusor collagen content
Changes in the electrical properties of detrusor
smooth muscle cells
Mirone V et al. J Urol 2004;172(4 Pt 1):1
386–1389
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Availables in OAB with BPH
 Alpha-blockers
 promote relaxation of the bladder neck and prostate
smooth muscle
 limited success in OAB related symptoms
Lee JY et al. BJU Int 2004; 94(6):817–820
 5-alpha-reductase inhibitors
 Epithelial apoptosis and atrophy
 reduce prostate size
 few effects to attenuate OAB symptoms
Chapple CR. BJU Int 2004;94(5):738–744
CHONNAM NATIONAL UNIVERSITY MEDICAL SCHOOL
The paradox: anti-cholinergic drugs
for BPH!
 Muscarinic receptor antagonists in BPH
 a precipitated factor of urinary retention
 Not routine use of anti-cholinergic agents as primary
therapy for BPH/LUTS or combined with alpha-blockers
Chapple CR. BJU Int 2004;94(5):738–744

OAB, failed in first line of treatment with alpha blocker,
 anti-cholinergic drugs proposed
 low risk of acute urinary retention Kaplan et al.
reported
Kaplan SA et al. J Urol 2005;174(6):2273–2275
CHONNAM NATIONAL UNIVERSITY MEDICAL SCHOOL
Inflammation and BPH
 MTOPS study
 Inflammation could be a risk factor of BPH progression
Roehrborn et al. J Urol 2005; AUA #1277
 BPH with inflammation
 older (64 vs. 62 years)
 Higher PSA level (3.3 vs. 2.5 ng/ml)
 higher prostatic volume (41 vs. 36 ml)
 fourfold increased risk of AUR (2.4 vs. 0.6%)
 risk of progression (21% Vs 13%)
 Inflammation plays a significant role in BPH symptoms
CHONNAM NATIONAL UNIVERSITY MEDICAL SCHOOL
Anti-inflammatory drugs treat BPH
symptoms?
 Diclofenac, ibuprofene, ketoprofen, loxoprofen,
 aspirin, cox-2 inhibitor
 Mechanisms of action
 diuresis reduction by renal blood flow reduction
 sedative effect on the hypersensitivity of the bladder
 neuronal conduction change to the bladder sphincter
 improvement of the sleep cycles
 Loxoprofen
 LUTS resistant to a first-line treatment
 improvement of the nocturia, 74%
Araki T et al. Acta Med Okayama 2004;58(1):45–49
CHONNAM NATIONAL UNIVERSITY MEDICAL SCHOOL
Botulinum toxin and BPH
; neurogenic bladder
 Bladder sphincter dyssynergia, non relaxing uretral sphincter,
 cauda equina lesion or peripheral neuropathy
 Transperineal, intraurethral injection
 BT A (50 IU and 100 IU) general anesthesia
 Total success rate; 84.5%
 Indwelling catheters or CIC discontinue (87%)
Mean maximum voiding pr
(cm H2O)
Maximal urethral closure pr
(cm H2O)
Post-void residual (ml)
Baseline
After treatment
p value
62 ± 40
43 ± 31
0.000
65 ± 36
48 ± 31
0.000
89 ± 112
0.000
l 226 ± 165
Kuo. J Uro 2003;170(5):1908–1912
CHONNAM NATIONAL UNIVERSITY MEDICAL SCHOOL
Botulinum toxin
; LUTS with BPH





Randomized, placebo-controlled study
Transperineal, no local anesthesia
200 IU of BT (Botox)
Medium follow-up, 20 months
Peak urinary flow 8 ->15 ml/s
Decline of value from baseline after 1 month treatment
AUA SS
54%
PSA
42%
Post void residual
60%
Prostate volume
54%
Maria et al. Urology 2003;62(2):259–264
CHONNAM NATIONAL UNIVERSITY MEDICAL SCHOOL
Botulinum toxin and BPH
; urinary retension






Symptomatic BPH with urinary retention and PVR
Mean age, 75: prostatic volume, > 30 g
Transurethrally on ten sites using rigid cystoscopy
200 IU of BT (Botox), general anaesthesia
Excellent results, 80% (6 months)
No side effect
Baseline
After 6month treatment
PVR (ml)
243
37
Peak urinary flow (ml/sec)
7.6
11.6
Prostatic volume (gm)
65
49
Kuo. Urology 2005;65(4):670–674
CHONNAM NATIONAL UNIVERSITY MEDICAL SCHOOL
Botulinum toxin and BPH
; transrectal application





2005 AUA congress
Multicentric study
Transrectally inject using ultrasound scan
100 IU, 200 IU
Without anaesthesia
Baseline
After 3month
treatment
IPSS
21
11
Peak urinary flow (ml/sec)
10
14
Complication
One AUR
No fecal and urinary incontinence
Larson et al. J Urol. 2005, AUA San Antonio, abstract 1386
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Botulinum toxin and BPH
; prostate volume
 Inclusion
 Prostate volume, 80 cc
 Peak urinary flow < 10 ml/s
 medium age, 69
 150 IU BT
 Follow up to 6 months
Baseline
IPSS
24
After 6 month treatment
9
Post-void residual (ml)
295
85
Peak flow rate (ml/sec)
8.2
18.1
Prostate volume (gm)
106
53
Guercini et al. J Urol. 2005, AUA San Antonio, abstract
1387
CHONNAM
NATIONAL UNIVERSITY MEDICAL SCHOOL
Conclusion
 Usual treatment of BPH
 alpha-blockers
 5-alpha-reductase inhibitors
 phytotherapy
 New therapeutic possibilities
 anti-diuretics
 anti-cholinergic drugs
 treatments in the decision, not clearly defined yet
 Should we use them as the second line or directly
as a first-line treatment?
CHONNAM NATIONAL UNIVERSITY MEDICAL SCHOOL
Conclusion
 Inflammation plays an important role in BPH
 vary therapeutic efficiency
 lack of clinical data
 Botulnum toxin
 important tool of the neuro-urology management
 hopeful treatment of BPH with real clinical improvements
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